Adolescent Health Care: A Practical Guide

Chapter 5

Vital Statistics and Injuries

Ponrat Pakpreo

Jonathan D. Klein

Lawrence S. Neinstein

Intentional and unintentional injuries are responsible for most morbidity and mortality in adolescents. Injuries are preventable health problems, but the prevention of injuries poses considerable challenges to medical and public health professionals. The public health approach to injury prevention includes educational strategies, environmental modifications, and engineering techniques (Rivara and Aitken, 1998). The success of these interventions also relies on accurate and comprehensive reporting of morbidity and mortality data related to adolescent injury. This chapter presents an overview of mortality and morbidity in adolescents as well as available data on intentional and unintentional injuries. The chapter will be organized in the following manner:

Demographics of the adolescent population.

Data sources of vital statistics on adolescents and young adults including demographics, morbidity, and mortality.

Mortality in adolescents including leading causes, unintentional injuries, intentional injuries, cancer, and trends in mortality.

Focus on unintentional injuries.

Recovery from injuries.

Prevention of injuries.

Morbidity including hospitalizations and ambulatory visit data.

Demographics

General:In 2005, adolescents 10- to 19-years old were more than 42 million or 14.2% of the U.S. population and 20.8 million young adults 20- to 24-years old comprised an additional 7.1%. From 2000 to 2005, the adolescent population aged 10 to 14 years increased 1.4% compared with the 4.7% increase among 15- to 19-year olds. Table 5.1demonstrates a rise in the actual number of the 10- to 14-year-old adolescent population since 1980 and among those 15- to 19-years old since 1990. However, the percentages of the total U.S. population represented by these age-groups have declined since 1980.

Projections:It is projected that by 2010, the 10- to 19- year-old population will have decreased to 41.1 million, a decline of just >2% (Table 5.1). It is projected that the 20- to 24-year-old population will increase by 3.4% to 21.7 million. The number of adolescents aged 10- to 19- years is projected to continue to increase through 2050; however, as a percentage of the total U.S. population, the number of adolescents, although decreasing, appears to stabilize by 2010. In the 20- to 24-year-old population, this percentage, although increasing since 1998, is projected to decrease after 2004 and then stabilize by 2020.

Ethnicity:Hispanic adolescents, 10- to 14-years old, are one of the fastest growing segments of the U.S. population, having increased 19.6% between 2000 and 2004. Hispanic teens aged 10 to 19 years comprise 2.4% of the entire 2004 U.S. population and 17.2% of the U.S. Hispanic population. Hispanic youth are second in overall numbers compared with non-Hispanic whites. African-American youth aged 10 to 19 years are third (U.S. Census Bureau, 2006) comprising 15.7% of that age-group in the United States.

Data Sources

Adolescent demographics, morbidity, mortality, and health behaviors change from year to year. The most current data are typically available on the Internet and can be accessed by readers seeking the most up-to-date information.

Demographic and General Health Data

Health, United States, 2006:Available at http://www.cdc.gov/nchs/hus.htm. Health, United States is an annual report on trends in health statistics. The report consists of two main sections—a chartbook containing text and figures that illustrate major trends in the health of Americans and a trend tables section that contains 147 detailed data tables. This Web site is updated when new versions of this publication are available. The Web site also includes an executive summary, a highlights section, an extensive appendix, a reference section, and an index.

The 2006 Statistical Abstract, U.S. Census Bureau:Available at http://www.census.gov/compendia/statab/. Each year the Census Bureau publishes data related to U.S. demographics, health, education, and a wide range of other areas.

The National Health Interview Survey (NHIS):Available at http://www.cdc.gov/nchs/nhis.htm. The NHIS is a

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multistage probability sample survey conducted annually by the National Center for Health Statistics (NCHS) through in-home interviews of the civilian noninstitutionalized U.S. population. The NHIS sample frame is also linked to several other national health survey efforts. The objectives of the NHIS surveys are to monitor the health and health care of the U.S. population through the collection and analysis of data on a broad range of health topics. Current topics include the following (National Center for Health Statistics, 2005):

National Vital Statistics System:Available at http://www.cdc.gov/nchs/nvss.htm. The National Vital Statistics System is the oldest and most successful example of intergovernmental data sharing in public health. These data include births, deaths, marriages, divorces, and fetal deaths that are recorded across the United States.

Healthy People 2010:Available at http://www.healthypeople.gov/and outlines national health promotion and disease prevention objectives that are monitored and updated over time. Of the 467 Healthy People 2010 objectives for children and adults, 107 are relevant to adolescents and young adults. Adolescent health experts convened and identified 21 critical health objectives, which reflect some of the leading causes of morbidity and mortality among adolescents and young adults. Table 5.2 lists the 21 critical health objectives as well as baseline data and 2010 target goals.

Healthy Campus 2010: Available at http://www.acha.org/info_resources/hc2010.cfm. Healthy Campus 2010 establishes national college health objectives and serves as a basis for developing plans to improve student health. Healthy Campus 2010 is a series of health objectives parallel to Healthy People 2010 but adapted for the college population.

TABLE 5.1Actual and Projected Number of Adolescents, United States (in Thousands)

5–9 yr Number (%)

10–14 yr Number (%)

15–19 yr Number (%)

20–24 yr Number (%)

Adapted from United States Census Bureau. Statistical abstract of the United States, 2005–2006, 125th ed. Washington, DC: US Bureau of the Census, 2006.

Actual

1980

16,700 (7.4)

18,242 (8.1)

21,168 (9.3)

21,319 (9.4)

1990

18,040 (7.3)

17,065 (6.9)

17,893 (7.2)

17,893 (7.2)

1998

20,510 (7.4)

19,825 (7.1)

19,640 (7.2)

18,167 (6.6)

2000

20,550 (7.3)

20,530 (7.3)

20,221 (7.2)

18,961 (6.7)

2004

19,775 (6.8)

21,193 (7.3)

20,477 (7.0)

20,971 (7.1)

2005

19,467 (6.6)

20,838 (7.1)

21,172 (7.2)

20,823 (7.0)

Projected

2010

20,706 (6.7)

19,767 (6.3)

21,336 (6.9)

21,676 (7.0)

2020

22,564 (6.7)

21,914 (6.5)

21,478 (6.4)

20,751 (6.2)

2030

23,790 (6.5)

23,539 (6.5)

23,503 (6.5)

23,136 (6.4)

2040

25,550 (6.5)

24,953 (6.4)

24,824 (6.3)

24,897 (6.3)

2050

27,521 (6.6)

26,974 (6.4)

26,572 (6.3)

26,297 (6.3)

Mortality Data

Health, United States, 2006:As described in “Demographic and General Health Data” section in the preceding text.

Deaths, Final Data for 2003:This yearly publication is available at the NCHS Web site. The 2003 final report is at http://www.cdc.gov/nchs/products/pubs/pubd/hestats/finaldeaths03/finaldeaths03.htm.

National Center for Injury Prevention and Control (NCIPC):Available at http://www.cdc.gov/ncipc/. The NCIPC has a vast array of data and information on injuries and injury prevention in all age-groups. Also at this site are two interactive data tools: WISQARS and injury maps.

WISQARS—Web-based Injury Statistics Query and Reporting System is available at http://www.cdc.gov/ncipc/wisqars/default.htm. This site is the NCIPC's interactive, online database that provides customized injury-related mortality data and nonfatal injury data. One can also stratify results by age, gender, ethnicity, and region of the country.

Injury maps,the NCIPC's interactive mapping system, available at: http://www.cdc.gov/ncipc/maps/default.htm, helps identify and communicate the impact of injury deaths in a particular county, state, region, or the entire United States.

Morbidity Data Including Diseases, Health Risks, and Health Behaviors

The National Health and Nutrition Examination Survey (NHANES):Available at http://www.cdc.gov/nchs/nhanes.htm,

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NHANES is another survey conducted by the NCHS on overall health risks and behaviors. Data collection is unique in that it combines a home interview with objective health measures and a physical examination conducted in a mobile examination center. The goals of this survey include the following:

To estimate the number and percentage of persons in the U.S. population and designated subgroups with selected diseases and risk factors

To monitor trends in prevalence, awareness, treatment, and control of selected diseases or conditions including those unrecognized or undetected

To study the relationship between diet, nutrition, and health, including a focus on iron deficiency anemia and other nutritional disorders, children's growth and development, and obesity/physical fitness

To explore emerging public health issues and new technologies

To establish a national probability sample of genetic material for future genetic testing

The National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey: Available at http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm, these surveys focus on characteristics of patients' visits to physicians' offices, hospital outpatient settings, and emergency departments. Additionally, these surveys collect data on diagnoses and treatments, prescribing patterns, and characteristics of clinical facilities.

Reproductive health: The National Survey of Family Growthis available at http://www.cdc.gov/nchs/nsfg.htm has data about reproductive health behaviors.

National Survey of Children with Special Health Care Needs:Available at http://www.cdc.gov/nchs/about/major/slaits/cshcn.htm, this survey assesses the prevalence and impact of special health care needs among children in all 50 states and the District of Columbia.

Cancer data: National Cancer Institute, Surveillance Epidemiology and End Results (SEER)data are available at http://seer.cancer.gov/publicdata/. The SEER Public-Use Data include SEER incidence and population data associated by age, sex, race, year of diagnosis, and geographical areas (including SEER registry and county).

Infectious diseases: The Summary of Notifiable Diseasesis available each year in the MMWR. Available at www.cdc.gov/mmwr.

spinal cord injuries. This research has been conducted at the University of North Carolina at Chapel Hill since 1965. Three annual reports are compiled each spring: (a) Annual Survey of Football Injury Research, (b) Annual Survey of Catastrophic Football Injuries; and (3) Annual Report of National Center for Catastrophic Sports Injury Research.

Youth Risk Behavior Survey (YRBS):Available at http://www.cdc.gov/HealthyYouth/yrbs/index.htm. The Youth Risk Behavior Surveillance System was developed in 1990 to monitor priority health-risk behaviors that contribute to the leading causes of death, disability, and social problems among youth and adults in the United States. Behaviors studied include tobacco use, unhealthy dietary behaviors, inadequate physical activity, alcohol and other drug use, sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs) (including HIV infection), and behaviors that contribute to unintentional injuries and violence. The survey examines the prevalence of health-risk behaviors, trends over time, comparable data among subgroups of adolescents, and progress toward Healthy People 2010 objectives.

The YRBS is conducted by staff members of the state departments of education with assistance from the Centers for Disease Control and Prevention (CDC) every 2 years. The survey includes representative samples of 9th through 12th grade students both in public and private schools. The Youth Risk Behavior Surveillance System also includes three additional national surveys conducted by CDC:

YRBS, conducted in 1992 as a follow-up to the National Health Interview Survey among approximately 11,000 persons aged 12 to 21 years.

National College Health-Risk Behavior Survey, conducted in 1995 among a representative sample of approximately 5,000 undergraduate students.

National Alternative High School Youth Risk Behavior Survey, conducted in 1998 among a representative sample of approximately 9,000 students in alternative high schools.

Some notable statistics reported by the 2003 YRBS are presented in Table 5.3.

National College Health Assessment (NCHA):Available at http://www.acha-ncha.org/index.html. The American College Health Association (ACHA)-National College Health Assessment (NCHA) is a national research effort organized by ACHA to assist health care providers, health educators, counselors, and administrators in collecting data about college students' habits, behaviors, and perceptions on the most prevalent health topics. Topics include alcohol, tobacco, and other drug use; sexual health; weight, nutrition, and exercise; mental health; and injury prevention, personal safety, and violence. Results of recent studies are reviewed in Chapter 84.

Add Health:Available at http://www.cpc.unc.edu/addhealth. Add Health is a nationally representative study that explores the causes of health-related behaviors of adolescents in grades 7 through 12 and their outcomes in young adulthood. Add Health examines how social contexts (families, friends, peers, schools, neighborhoods, and communities) influence adolescents' health and risk behaviors. Wave 1 was initiated in 1994, and is the largest, most comprehensive survey of adolescents ever undertaken. Data at the individual, family, school, and community levels were collected in two waves between 1994 and 1996. In 2001 and 2002, Add Health respondents, 18- to 26-years old, were reinterviewed in a third wave to investigate the influence that adolescence has on young adulthood. Numerous public and restricted release datasets are available. Longitudinal data are collected on such attributes as height, weight, pubertal development, mental health status (focusing on depression, the most common mental health problem among adolescents), and chronic and disabling conditions. Data are gathered from adolescents themselves, their parents, and school administrators. Already existing databases provide information about neighborhoods and communities.

Substance Abuse: Monitoring the Future Studyis available at www.monitoringthefuture.org. Monitoring the Future (MTF) is an ongoing study of the behaviors, attitudes, and values of American secondary school students, college students, and young adults. Each year, approximately 50,000 8th, 10th, and 12th grade students are surveyed (12th graders since 1975, and 8th and 10th graders since 1991). In addition, annual follow-up questionnaires are mailed to a sample of each graduating class for a number of years after their initial participation. This study provides perhaps the most complete and comprehensive examination of substance use and abuse patterns both cross-sectionally and longitudinally in the United States. Volume I of the annual MTF report focuses on secondary school students and Volume II focuses on college students and young adults. Results are reviewed inChapters 68 and 84.

HIV, human immunodeficiency virus. Bolded objectives numbers indicate critical health outcomes. Behaviors that substantially contribute to important health outcomes are in normal font.a 2010 target not provided for adolescent/young adult age-group.b Baseline and target inclusive of age-groups outside of adolescent/young adult age parameters.c Developmental objective-baseline and 2010 target to be provided by 2005.d Proposed baseline is shown but has not yet been approved by the Healthy People 2010 Steering Committee.Adapted from the National Adolescent Health Information Center. 21 critical health objectives for adolescents and young adults. Data from the U.S. Department of Health and Human Services. Healthy People 2010, Vol. 1 and 2. Washington, DC: U.S. Government Printing Office, Available at http://nahic.ucsf.edu/nationalinitiative. November 2000.

The ten leading causes of death for youth aged 10 to 14 years vary slightly from those of older adolescents and young adults. The leading causes of mortality for each age-group (per 100,000) are shown in Table 5.4 (National Center for Injury Prevention and Control, 2006). Unintentional injuries, homicides, and suicides are the top three causes of death in the 15- to 24-year-old population. In the 10 to 14 years age-group both unintentional injuries and suicide are the leading causes. Malignant neoplasms are the second highest cause of mortality. HIV-related deaths are sixth in young adults aged 25 to 34 years and eighth in the leading causes of death among 15- to 24-year olds.

In general, the leading cause of death is the same among different ethnicities in all age-groups except those

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aged 15 to 44 years. Among individuals aged 15 to 34 years, unintentional injuries are the leading cause of death for all races except African-Americans, in whom homicides are the leading cause of death. Table 5.5 shows the leading causes of death by race among adolescents 10 to 19 years of age. Homicide also ranks higher as a cause of death in this age-group for the Hispanic population compared with the non-Hispanic population.

TABLE 5.3Percentage of High School Students Who Engaged in Selected Health-Risk Behaviors, by Grade—United States Youth Risk Behavior Survey, 2005

Behavior

9th Grade

10th Grade

11th Grade

12th Grade

Total

a When riding in a car or truck as a passenger.b When riding on a motorcycle.c When riding on a bicycle.d Rode at least once during the 30 days preceding the survey in a car or other vehicle driven by someone who had been drinking alcohol.e Fought at least once during the 12 months preceding the survey.f Carried a gun, knife, or club at least 1 day during the 30 days preceding the survey.g Ever tried smoking, even one or two puffs.h Smoked cigarettes on one or more of the 30 days preceding the survey.j Used chewing tobacco or snuff on one or more of the 30 days preceding the survey.k Ever drank one or more drinks.l Drank five or more drinks of alcohol on at least one occasion during the 30 days preceding the survey.m Ever used marijuana.n Ever tried any form of cocaine (i.e., powder, “crack,” or “freebase”).o Respondents were classified as injecting-drug users only if they (a) reported injecting-drug use not prescribed by a physician and (b) answered “one or more time” to any of the following questions: “During your life, how many times have you used any form of cocaine including powder, crack, or freebase?” “During your life, how many times have you used heroin (also calledsmack, junk,or China White)?” “During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice)?” or “During your life, how many times have you taken steroid pills or shots without a doctor's prescription?”p Among respondents who had sexual intercourse during the 3 months preceding the survey.q Ate five or more servings of fruits and vegetables (fruit, fruit juice, green salad, and cooked vegetables) during the 7 days preceding the survey.r During the 12 months preceding the survey.s Activities that did not cause sweating or hard breathing for at least 30 minutes at a time on five or more of the 7 days preceding the survey.Adapted from Centers for Disease Control and Prevention. Youth risk behavior surveillance, 2005. MMWR CDC Surveill Summ2006b;55(SS-5):1–108.

Rarely or never used safety beltsa

10.9

8.6

10.1

10.8

10.2

Rarely or never wore motorcycle helmetsb

36.8

31.9

38.2

39.5

36.5

Rarely or never wore bicycle helmetsc

83.0

84.3

82.2

84.0

83.4

Rode with a drinking driverd

27.9

27.8

28.0

30.1

28.5

Participated in a physical fighte

43.5

36.6

31.6

29.1

35.9

Carried a weaponf

19.9

19.4

17.1

16.9

18.5

Lifetime cigarette useg

48.7

52.5

57.5

60.3

54.3

Current cigarette useh

19.7

21.4

24.3

27.6

23.0

Current smokeless tobacco usej

7.6

7.5

8.4

8.4

8.0

Lifetime alcohol usek

66.5

74.4

76.3

81.7

74.3

Current episodic heavy drinkingl

19.0

24.6

27.6

32.8

25.5

Lifetime marijuana usem

29.3

37.4

42.3

47.6

38.4

Lifetime cocaine usen

6.0

7.2

8.7

8.9

7.6

Lifetime ecstacy use

5.8

6.0

6.5

6.7

6.3

Lifetime methamphetamine use

5.7

5.9

6.7

6.4

6.2

Ever injected drugso

2.4

2.3

1.7

1.7

2.1

Ever had sexual intercourse

34.3

42.8

51.4

63.6

46.8

Sexual intercourse with four or more partners (lifetime)

9.4

11.5

16.2

21.4

14.3

Used condom during last sexual intercoursep

74.5

65.3

61.7

55.4

62.8

Used birth control pills before last sexual intercoursep

7.5

14.3

18.5

25.6

17.6

Ate fruits and vegetablesq

21.3

21.4

18.8

18.3

20.1

Played on a sports teamr

60.4

58.0

54.9

49.2

56.0

Engaged in moderate physical activitys

36.9

38.5

34.4

32.9

35.8

Made a suicide plan in last 12 mo

13.9

14.1

12.9

10.5

13.0

TABLE 5.4Ten Leading Causes of Death, United States, 2004, by Age Group

Unintentional injuries are the fifth leading cause of death in the United States for the total population, but are the leading cause of death among 1- to 44-year olds. The leading cause of death due to unintentional injury is motor vehicle crashes. In 2004, when adolescents aged 10 to 19 years accounted for 14.3% of the total population in the United States, they also accounted for 15.8% (6,608) of all motor vehicle deaths (U.S. Census Bureau, 2006, National Center for Injury Prevention and Control, 2006a). Of these deaths, two out of every three were male adolescents (Insurance Institute for Highway Safety, 2006a). The data is particularly striking for adolescent drivers. Although the 12 million adolescent drivers represent only 6% of total drivers, they account for approximately 14% of the fatal crashes (American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention and Committee on Adolescence, 2006). Unintentional injuries are discussed later in this chapter.

Intentional Injuries

Homicide

Homicide continues to be a major public health problem in the United States, particularly for young African-American males. Homicide remains the number two cause of death in the 15- to 24-year-old population and the number one cause of death among African-American males aged 15 to 24 years. Between 1990 and 2002, the overall age-adjusted homicide rate for all adolescents decreased by 35% to 6 deaths per 100,000 persons, reversing an upward trend seen in the late 1980s and early 1990s (National Center for Injury Prevention and Control, 2006). Between 1985 and 1993, the homicide victimization rate for 14- to 17-year olds

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increased approximately 170%, and after 1993, adolescent homicide victimization rates declined to levels similar to those seen before 1985.

TABLE 5.5United States, 2004, Leading Cause of Death among 10- to 19-Year-Olds by Race, Absolute Numbers

Rank

White

Black

Hispanic

All Races

HIV, human immunodeficiency virus. Adapted from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, WISQARS, United States, 2006. Leading causes of death report and from the National Vital Statistics Reports. Available at http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. Last accessed 12. 2006.

1

Unintentional injury70,110

Homicide1,129

Unintentional injury1,169

Unintentional injury8,365

2

Suicide1,642

Unintentional injury1,013

Homicide532

Homicide2,139

3

Malignant neoplasms959

Malignant neoplasms217

Suicide253

Suicide1,983

4

Homicide932

Suicide203

Malignant neoplasms249

Malignant neoplasms1,224

5

Heart disease338

Heart disease171

Congenital anomalies63

Heart disease528

6

Congenital anomalies325

Congenital anomalies96

Heart disease61

Congenital anomalies441

7

Influenza and pneumonia91

Chronic low-respiratory disease79

Influenza and pneumonia19

Chronic low-respiratory disease159

8

Cerebrovascular events82

Anemias41

Cerebrovascular events17

Influenza and pneumonia116

9

Chronic low-respiratory disease75

HIV37

Chronic low-respiratory disease12

Cerebrovascular events112

10

Benign neoplasms64

Diabetes mellitus34

Two-tied benign neoplasias and pregnancy complications11 each

Septicemia93

Trends by race

The homicide rate among African-American male adolescents increased by 135% between 1950 and 1990. The rate peaked at 163.21 per 100,000 in 1993 and subsequently decreased by 49% to a rate of 82.8 per 100,000 in 2002. Still, the current rate is eight times that of white males and nearly three times that of Hispanic males in the same age-group. Compared with peak rates in the early 1990s the greatest declines in homicide rates are among Hispanic males and females 15- to 19-years old (57% and 61% reduction, respectively) and black males 15- to 19-years old (61% reduction) (National Center for Injury Prevention and Control, 2006a). Figures 5.1 and 5.2 from the U.S. Department of Justice, demonstrate the trends in homicide victimization by age-group, gender, and race over time. In 2004, the highest homicide rates were among older adolescents and young adults 18- to 24-years old. Males have higher rates of homicide victimization and perpetration compared to females. Adolescent homicide victims most often died due to arson (28.4%), poisoning (26.5%), gang-related killings (25%), and sex-related crimes (19.8%). Figures 5.3 and 5.4 demonstrate the rates of homicide offenders by age-group, gender, and race over time. Adolescent homicide offenders were more often implicated in gang-related killings (30%) and felony murders (15%). More than 75% of homicides in older adolescents and young adults involved firearms. In 2004, African-American males 18- to 24-years old had the highest homicide victimization rates at 95.5 per 100,000, more than double the rate for black males 25 years and older (38.3 per 100,000) and four times the rate for black males 14- to 17-years old (25.8 per 100,000) (U.S. Department of Justice, 2006). Although rates appeared to be increasing again from 2000 to 2003, there appears to be a drop off in 2004 (U.S. Department of Justice, 2006).

Suicide

Incidence

Suicide has changed from a problem of predominantly older persons to one that affects primarily adolescents and young adults. Adolescent suicide rates remained stable between 1900 and 1955 and then began to rise dramatically. Currently, suicide is the third leading cause of death for adolescents and young adults aged 10 to 14 years and 15 to 24 years, respectively (Centers for Disease Control and Prevention, 2006). The rate within that age-group

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escalated from 4.5 per 100,000 in 1950 to 13.57 per 100,000 in 1994. Since then, the suicide rate in this age-group has declined. In 2004, the suicide rate was 10.35 per 100,000 accounting for 4,316 deaths within the 15- to 24-year-old population. This represents almost 13% of all suicides as well as almost 13% of all deaths within that age-group. For both 15 to 19 and 20- to 24-year olds, suicide rates are highest among Native Americans and whites. African-Americans had the lowest rates among 15- to 19-year olds and Asians had the lowest rate among 20- to 24-year olds (National Center for Injury Prevention and Control, 2006). The ratio

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of attempted to completed suicides among adolescents is estimated to be between 50:1 and 100:1, with the incidence of unsuccessful attempts being higher among females than among males. The true number of deaths from suicide may actually be much higher than indicated, because some suicide deaths are recorded as “accidental” (American Academy of Pediatrics Committee on Adolescence, 2000).

Ingestion of pills is the most common method among adolescents who attempt suicide. Firearms, used in approximately 50% of adolescent suicides, cause the greatest number of deaths for male and female adolescents who complete suicides. More than 90% of suicide attempts involving a firearm are fatal because there is little chance for rescue. Firearms in the home, regardless of whether they are kept unloaded or locked, are associated with a higher risk of adolescent suicide (American Academy of Pediatrics Committee on Adolescence, 2000). Among younger adolescents 10- to 14-years old who complete suicides, suffocation is the most common method.

Suicide attempts

In a national survey of high school students in 2003, 16.9% reported having seriously considered attempting suicide during the 12 months preceding the survey. Overall, female students (21.3%) were significantly more likely than male students (12.8%) to have considered suicide. More serious ideation, having made a specific plan to attempt suicide during the preceding 12 months was reported by 16.5% of students nationwide. Female students were more likely to have made a plan than were male students (18.9% versus 14.1%). Furthermore, 8.5% of high school students reported having attempted suicide at least once within the previous 12 months. More female than male students reported having made an attempt (11.5% versus 5.4%). Hispanic and white females most often reported considering suicide, making a suicide plan, and having attempted suicide than other female and male students. Of all students who reported a history of suicide attempts, only 2.9% had been treated by a doctor or nurse for an attempted suicide-related injury, poisoning, or overdose (Centers for Disease Control and Prevention, 2004b).

Firearm Injuries

In 2004, in the United States, there were 29,569 (9.95/100,000) deaths from firearm injuries, including those related to accidents, suicides, and homicides (National Center for Health Statistics, 2006, accessed 12/4/2006, http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html). Table 5.6 reviews firearm mortality rates among those 1 through 34 years of age. Most of the firearm deaths in the adolescent and young adult age-group are related to suicide or homicide. Between 1990 and 2004, the age-adjusted death rate for firearm injuries decreased by 28% and has remained at a rate near 10 per 100,000 since 1999. In 2004, the largest

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absolute numbers and rates of firearm-related deaths occurred in the 20- to 24-year (19.29 per 100,000) and the 25- to 29-year age-groups (16.90 per 100,000). Among firearm deaths from individuals aged 10 to 29 in 2004, 47% occurred among white males, 40% among African-American males, 6% among white females, and 3% among African-American females. However, the death rate is highest among African-American males aged 20 to 24 years at 107.64 per 100,000, which is five times that of white males of the same age. American Indian/Alaskan Native males aged 20 to 24 have the next highest death rate at 26.58 per 100,000. Adolescent male (15 to 24 years old) deaths due to firearms were eight times the rate among females (National Center for Injury Prevention and Control, 2006a).

TABLE 5.6Firearm Mortality Rates among Children, Youth, and Young Adults, 1- to 34-Year Olds, United States, 2004 (Rates per 100,000)

Cause of Death

<5 yr

5–9 yr

10–14 yr

15–19 yr

20–24 yr

25–29 yr

30–34 yr

Adapted the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, WISQARS, United States, 2004. Injury mortality reports. Available at: www.cdc.gov/ncipc/osp/data.htm., Last accessed 12. 2006.a Figure does not meet standard of reliability or precision.

Male

Total

White

0.14

0.20

1.48

14.41

22.30

19.45

17.01

African-American

1.09a

0.99a

3.49

55.17

107.64

102.09

64.87

Suicide

White

0a

0a

0.49

7.10

11.67

10.25

10.38

African-American

0a

0a

0.39a

3.71

10.69

10.19

7.82

Homicide

White

0.07a

0.14a

0.63

6.53

9.68

8.60

6.23

African-American

0.73a

0.62a

2.88

49.95

94.92

90.24

55.75

Female

Total

White

0.13a

0.23

0.31

2.35

2.77

2.76

3.53

African-American

0.94a

0.58a

0.80

5.85

7.9

7.28

6.99

Suicide

White

0a

0a

0.10a

1.07

1.21

1.45

2.01

African-American

0a

0a

0.06a

0.74a

1.08a

0.84a

0.96a

Homicide

White

0.10a

0.20a

0.16

1.19

1.48

1.21

1.42

African-American

0.81a

0.39a

0.74a

5.05

6.56

6.37

5.89

Cancer

Excluding intentional and unintentional injuries, cancer is the leading cause of death in adolescents and is the leading cause of death by disease. It is the second cause of death among younger adolescents 10- to 14-years old and ranks fourth among 15- to 24-year olds (National Center for Injury Prevention and Control, 2006, National Center for Health Statistics, 2006). In 2005, the estimated number of children younger than 15 years old diagnosed with cancer was 9,510 and 1,585 were estimated to have died from cancer (American Cancer Society, 2005). The overall annual incidence of cancer for adolescents has increased from 141.4 per million in 1975–1981 to 162.6 per million in 1996–2002 (Ries et al., 2005). On an average, 1 or 2 of every 10,000 children in the country develops cancer (National Cancer Institute, 2005, http://www.cancer.gov/cancertopics/factsheet/Sites-Types/childhood.).

The types of tumors that occur in the adolescent population, especially those 15- to 19-years old, differ significantly from those that predominate in younger children and adults. During adolescence, there are increases in incidence and mortality due to Hodgkin disease, germ cell tumors, central nervous system tumors, and non-Hodgkin lymphoma, thyroid cancer, malignant melanoma, and acute lymphoblastic leukemia (Ries et al., 1999). Table 5.7 lists the incidence, mortality, and 5-year survival rates of the top cancer sites among 5- to 19-year olds. Of the 12 major types of childhood cancers, leukemias (blood cell cancers) and brain and other central nervous system tumors account for more than one half of new cases. Leukemias make up approximately one third of childhood cancers and it is the number one cause of death from malignancies among 15- to 24-year olds. Overall 5-year survival rates for adolescents aged 10 to 14 years with cancer have improved from 58.8% (1975–1977) to approximately 80% (1996–2002) and for those aged 15 to 19 the 5-year survivals rates have improved from 67.7% to 79.7% (National Cancer Institute, 2005). This is reflected in a decreasing cancer mortality rate.

Human Immunodeficiency Virus

HIV remains one of the ten leading causes of death in all ages between 15 and 54 years, although each ranking has decreased since 1994 and HIV has fallen out of the top ten

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causes of death in those younger than 15 and older than 54. HIV infection ranks 14th for ages 10 to 14 years, 10th for ages 15 to 24, and 6th for ages 25 to 34 (National Center for Injury Prevention and Control, 2006). HIV mortality in the second and third decades of life often represents infection acquired during the teen years.

TABLE 5.7Childhood Cancer, SEER Incidence, Mortality, and 5-Year Survival Rates (per 100,000) for Top Cancer Sites by Age Group 2000–2003

Death rates from all causes have actually decreased over the past few decades (Tables 5.8 and 5.9), but the nature of youth deaths has changed drastically. Nevertheless, death rates for adolescents and young adults are still higher in 2004 than they were in 1950 for deaths due to suicides and homicides. Injuries cause more adolescent deaths than all diseases and natural causes combined. At least one U.S. adolescent between 10 and 19 years of age dies as the result of an injury every hour, every day. Unintentional injury accounts for approximately 60% of all adolescent injury-related deaths; the remaining 40% are attributed to violence (National Center for Health Statistics, 2000; Deal et al., 2000). Advanced technology has helped to keep more adolescents alive after experiencing an event that years ago might have been fatal. However, there is ample room for improvement in implementing prevention efforts that will reduce the incidence of adolescent injury altogether. More than 75% of all deaths among persons 15- to 24-years old are due to four causes—motor vehicle crashes, other unintentional injuries, homicide, and suicide. Additional data regarding adolescent unintentional injuries are discussed in the following section.

Unintentional Injuries

Unintentional injuries account for 44% of all injury deaths to children and adolescents in the United States. Among youth aged 1 to 19 years, unintentional injuries are responsible for more deaths than homicide, suicide, congenital anomalies, cancer, heart disease, respiratory illness, and HIV combined (Deal et al., 2000). Table 5.10 is a summary of unintentional/accidental deaths by age and type in 2004. Tables 5.11 through 5.13 give the death rates and number of deaths due to all intent injuries among adolescents by event, race, ethnicity, and sex in 2003 for 10- to 14-year-old, 15- to 19-year-old, and 20- to 24-year-old adolescents.

National injury surveillance provides more information about treatment of injuries (NSC, 2006). In 2002, in personal household interviews (National Health Interview Survey), 23.7 million people reported seeking medical care for an injury; a survey of hospitals (National Hospital Discharge Survey) found that 2.7 million people were hospitalized for an injury. Additionally, 39.2 million patients in private

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physicians' offices reported that they were treated in an emergency room for an injury (National Ambulatory Medical Care Survey). In 2003, the estimated cost of fatal and nonfatal injuries was >$607 billion, approximately $5,700 per household (National Safety Council, 2006). The number of nonfatal injuries is significantly greater than fatal injuries, at more than 15,000 per 100,000 for ages 15 to 19, and approximately 13,000 per 100,000 (Centers for Disease Control and Prevention, 2004a). Among 10- to 19- year olds, most nonfatal injuries are due to unintentional injury (90.7%), assault (7.9%), and self-harm (1.3%).

TABLE 5.8Mortality Rates (per 100,000) for Common Causes of Death among Children and Adolescents, United States, Trends over Selected Years 1950–2004

Cause and Age Group (yr)

1950

1960

1970

1980

1985

1987

1992

1998

2002

2004

Adapted from National Center for Health Statistics. National vital statistics reports. Table 5.7. Deaths and death rates for 10 leading causes of death in specified age groups, United States, 2004, Vol. 54. No. 19. Hyattsville, MD: US DHHS, June 28, 2006; and CDC. WISQARS, accessed 12/2006.

Accidents, all

5–14

20.1

26.0

20.1

15.0

12.5

12.3

9.3

8.3

6.6

6.62

15–24

48.2

58.4

68.7

61.7

48.4

8.9

37.8

35.9

38.0

37.86

Motor vehicle accidents

5–14

8.8

7.9

10.2

7.9

6.8

7.0

5.2

4.8

3.9

3.93

15–24

34.4

38.0

47.2

44.8

36.1

37.8

28.5

26.9

28.2

28.15

Homicide

5–14

0.5

0.5

0.9

1.2

1.2

1.2

1.6

1.2

0.9

0.87

15–24

6.3

5.9

11.7

15.6

12.1

14.0

22.2

14.8

12.9

12.39

Suicide

5–14

0.2

0.3

0.3

0.4

0.8

0.7

0.9

0.8

0.6

0.64

15–24

4.5

5.2

8.8

12.3

12.9

12.9

13.0

11.1

9.9

10.35

Malignant neoplasms

5–14

6.7

6.8

6.0

4.3

3.5

3.3

3.0

2.6

2.6

2.5

15–24

8.6

8.3

8.3

6.3

5.4

5.1

5.0

4.6

4.3

4.0

Human immunodeficiency virus

5–14

—

—

—

—

—

—

0.6

0.1

0.1

0.1

15–24

—

—

—

—

—

—

3.4

0.5

0.4

0.5

Diseases of the heart

5–14

2.1

1.3

0.8

0.9

0.9

1.2

0.8

0.8

0.6

0.6

15–24

6.8

4.0

3.0

2.9

2.8

3.6

2.7

2.8

2.5

2.3

Congenital anomalies

5–14

2.4

3.6

2.2

1.6

1.4

1.3

1.2

0.9

1.0

0.9

15–24

1.8

2.7

2.1

1.4

1.2

1.3

1.2

1.2

1.2

1.2

Pneumonia and influenza

5–14

3.2

2.6

1.6

0.6

0.4

0.3

0.3

0.3

0.2

0.2

15–24

3.2

3.0

2.4

0.8

0.6

0.7

0.6

0.6

0.4

0.5

Cerebrovascular events

5–14

0.5

0.7

0.7

0.3

0.2

0.2

0.2

0.2

0.2

0.2

15–24

1.6

1.8

1.6

1.0

0.8

0.6

0.5

0.5

0.4

0.5

Total

5–14

60.1

46.6

41.3

30.6

26.3

25.6

22.5

19.9

17.4

16.6

15–24

128.1

106.3

127.7

115.4

95.9

99.4

95.6

82.3

81.4

78.9

Trends in Injury Deaths

Despite significant reductions in incidence rates since 1979, injuries remain a major health problem (and the leading cause of death) for children and adolescents. In the pediatric age-group, unintentional injury mortality has fallen by >45% since 1979, with the largest decreases among those aged 5 to 9 years and the smallest decrease among teenagers. Table5.14 reflects changes in childhood and adolescent injury rates by age-group over the last two decades and Table 5.15 shows the trend in unintentional injury and motor vehicle-related death rates throughout the last century (National Safety Council, 2004).

Morbidity

Deaths only partially convey the enormous damage caused by childhood injuries. It is estimated that for every childhood death caused by injury there are approximately 34 hospitalizations, 1,000 emergency department visits,

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many more visits to private physicians and school nurses, and an even larger number of injuries treated at home. Approximately 21 million children in the United States are injured each year. This equates to an injury rate of one in four children, or 56,000 nonfatal injury episodes each day that require medical attention or limit children's activity (Danseco et al., 2000).

TABLE 5.9Mortality Rates (per 100,000) of Adolescents Due to All Causes According to Race, Sex, and Age, United States, Trends in Selected Years 1950–2003

Race, Sex, and Age (yr)

1950

1960

1970

1980

1990

2000

2002

2003

Adapted from National Center for Health Statistics. Health, United States, 2006 with chartbook on trends in the health of Americans. Table35. Hyattsville, MD: US DHHS, 2006.

White male

5–14

67.2

52.7

48.0

35.0

26.4

19.8

18.4

18.4

15–24

152.4

143.7

170.8

167.0

131.3

105.8

109.7

108.9

White female

5–14

45.1

34.7

29.9

22.9

17.9

14.1

13.7

13.1

15–24

71.5

54.9

61.6

55.5

45.9

41.2

42.4

43.2

African-American male

5–14

95.1

75.1

67.1

47.4

41.2

28.2

28.9

26.8

15–24

289.7

212.0

320.6

209.1

252.2

181.4

172.6

171.3

African-American female

5–14

72.8

53.8

43.8

30.5

27.5

20.0

19.9

18.9

15–24

213.1

107.5

111.9

70.5

68.7

58.3

54.4

54.0

Total

5–14

60.1

46.6

41.3

30.6

24.0

18.0

17.4

17.0

15–24

128.1

106.3

127.7

115.4

99.2

79.9

81.4

81.5

Leading Causes of Injuries

Four types of injury—being struck by or against an object or person, falls, motor vehicle traffic-related injuries, and being cut by a sharp object—account for approximately 60% of all injury-related visits to emergency departments by adolescents. Of these four causes, only motor vehicle traffic-related injuries are a significant source of mortality. Sports injuries make up >40% of injuries classified as “being struck by or against an object or person.” At each age, the rate of such injuries among males is twice that among females (National Center for Health Statistics, 2000).

Injuries are the leading cause of death for persons between the ages of 1 and 44 years in the United States.

Unintentional injuries, suicide, and homicide cause >75% of all deaths in the adolescent age-group. Unintentional injuries cause approximately 42% of all deaths among 5- to 14-year olds and approximately 44% among 15- to 24- year olds. Intentional injuries comprise approximately 10% and 31% of deaths in these age-groups, respectively (National Center for Health Statistics, 2006c).

The 15 to 24 year age-group has the highest cost related to injury of any age-group in the United States. Estimated costs for this group reach almost $90 million annually. The estimated total cost for unintentional childhood injuries just falls short of $350 billion each year (Danseco et al., 2000).

TABLE 5.10Unintentional (Accidental) Deaths by Age and Type, United States, 2004

Age (yr)

All Types

Motor Vehicle

Drowning

Fires and Burns

Firearms

Falls

Poisoning

CDC. WISQARS. 2006, last accessed 12.4.2006.

10–14

1,540

1,013

138

87

35

26

47

15–19

6,825

5,224

304

66

80

87

643

20–24

8,624

5,763

270

120

92

154

1,616

Epidemiology

Age:

Years of monitoring have identified certain risk factors as fairly strong indicators of injury events. First and foremost, the risk of injury is clearly related to the physical, mental, and emotional developmental milestones of children or adolescents; for this reason, age is a predictable risk factor for injury. Infants are at greatest

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risk of burns, drowning, and falls. As children increasingly acquire mobility, poisonings join the list. Young school-aged children are at greatest risk of pedestrian injuries, bicycle-related injuries, motor vehicle occupant injuries, burns, and drowning. Adolescents are most likely to suffer from motor vehicle injuries and injuries resulting from firearms and other forms of violence (Rivara and Aitken, 1998). At 10 years of age slightly fewer than half of all deaths are caused by injury but, by 18 years, >80% are injury related (National Center for Health Statistics, 2006). For every type of injury, except bicycle deaths, there are substantial rate increases between early and late adolescence.

TABLE 5.11Crude Death Rates (per 100,000) and Number of Deaths Due to All Intent Injuries among Adolescents 10- to 14-Year-Olds by Event, Race, Ethnicity (Hispanic, Non-Hispanic), and Sex, United States, 2003

Male

Female

Both

Race

No.

Rate

No.

Rate

No.

Rate

a Rates based on 20 or fewer deaths may be unstable. Use with caution.Adapted the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, WISQARS, United States, Injury mortality reports. Available at: www.cdc.gov/ncipc/osp/data.htm. 2003.

All injury deaths

White

1,006

11.93

460

5.75

1, 466

8.92

Black

297

16.43

137

7.82

434

12.20

American Indian/Alaskan Native

37

24.14

13a

8.67a

50

16.49

Asian Pacific Islander

38

8.20

21

4.80

59

6.55

All races, Non-Hispanic

1,158

12.88

546

6.38

1,704

9.71

All races, Hispanic

218

11.66

85

4.76

303

8.29

All injury and adverse effects deaths

White

1,007

11.94

462

5.77

1,469

8.94

Black

298

16.49

139

7.94

437

12.28

American Indian/Alaskan Native

37

24.14

13a

8.67a

50

16.49

Asian Pacific Islander

38

8.2

21

4.8

59

6.55

All races, Non-Hispanic

1,160

12.90

549

6.42

1,709

9.74

All races, Hispanic

218

11.66

86

4.81

304

8.31

Cut/pierce deaths

White

8a

0.09a

3a

0.04a

11a

0.07a

Black

4a

0.22a

2a

0.11a

6a

0.17a

American Indian/Alaskan Native

0a

0a

0a

0a

0a

0a

Asian Pacific Islander

0a

0a

0a

0a

0a

0a

All races, Non-Hispanic

9a

0.10a

4a

0.05a

13a

0.07a

All races, Hispanic

3a

0.16a

1a

0.06a

4a

0.11a

Drowning deaths

White

56

0.66

21

0.26

77

0.47

Black

44

2.43

13a

0.74a

57

1.60

American Indian/Alaskan Native

3a

1.96a

1a

0.67a

4a

1.32a

Asian Pacific Islander

6a

1.29a

1a

0.23a

7a

0.78a

All races, Non-Hispanic

93

1.03

30

0.35

123

0.70

All races, Hispanic

16a

0.86a

6a

0.34a

22

0.60

Fall deaths

White

19a

0.23a

11a

0.14a

30

0.18

Black

2a

0.11a

1a

0.06a

3a

0.08a

American Indian/Alaskan Native

0a

0a

0a

0a

0a

0a

Asian Pacific Islander

2a

0.43a

1a

0.23a

3a

0.33a

All races, Non-Hispanic

19a

0.21a

9a

0.11a

28

0.16

All races, Hispanic

4a

0.21a

4a

0.22a

8a

0.22a

Fire/burn deaths

White

24

0.28

27

0.34

51

0.31

Black

20a

1.11a

15a

0.86a

35

0.98

American Indian/Alaskan Native

1a

0.65a

1a

0.67a

2a

0.66a

Asian Pacific Islander

1a

0.22a

0a

0a

1a

0.11a

All races, Non-Hispanic

43

0.48

37

0.43

80

0.46

All races, Hispanic

3a

0.16a

6a

0.34a

9a

0.25a

Residential fire/flame deaths

White

18a

0.21a

22

0.27

40

0.24

Black

18a

1a

15a

0.86a

33

0.93

American Indian/Alaskan Native

1a

0.65a

1a

0.67a

2a

0.66a

Asian Pacific Islander

1a

0.22a

0a

0a

1a

0.11a

All races, Non-Hispanic

36

0.40

33

0.39

69

0.39

All races, Hispanic

2a

0.11a

5a

0.28a

7a

0.19a

Firearm deaths

White

137

1.62

22

0.27

159

0.97

Black

67

3.71

22

1.26

89

2.50

American Indian/Alaskan Native

5a

3.26a

1a

0.67a

6a

1.98a

Asian Pacific Islander

7a

1.51a

0a

0a

7a

0.78a

All races, Non-Hispanic

182

2.02

37

0.43

219

1.25

All races, Hispanic

34

1.82

8*

0.45*

42

1.15

Motor vehicle, overall

White

508

6.02

286

3.57

794

4.83

Black

94

5.20

59

3.37

153

4.30

American Indian/Alaskan Native

19*

12.39*

6*

4*

25

8.24

Asian Pacific Islander

15*

3.24*

10*

2.29*

25*

2.77*

All races, Non-Hispanic

528

5.87

314

3.67

842

4.80

All races, Hispanic

107

5.72

47

2.63

154

4.21

Motorcyclist deaths

White

21

0.25

3*

0.04*

24

0.15

Black

3*

0.17*

1*

0.06*

4*

0.11*

American Indian/Alaskan Native

0*

0*

0*

0*

0*

0*

Asian Pacific Islander

1*

0.22*

0*

0*

1*

0.11*

All races, Non-Hispanic

24

0.27

3*

0.04*

27

0.15

All races, Hispanic

1*

0.05*

1*

0.06*

2*

0.05*

Pedal cyclist deaths

White

53

0.63

10*

0.12*

63

0.38

Black

14*

0.77*

2*

0.11*

16*

0.45*

American Indian/Alaskan Native

3*

1.96*

0*

0*

3*

0.99*

Asian Pacific Islander

4*

0.86*

1*

0.23*

5*

0.55*

All races, Non-Hispanic

63

0.70

13*

0.15*

76

0.43

All races, Hispanic

11*

0.59*

0*

0*

11*

0.30*

Pedestrian deaths

White

102

1.21

41

0.51

143

0.87

Black

22

1.22

18*

1.03*

40

1.12

American Indian/Alaskan Native

3*

1.96*

1*

0.67*

4*

1.32*

Asian Pacific Islander

0*

0*

0*

0*

0*

0*

All races, Non-Hispanic

106

1.18

54

0.63

160

0.91

All races, Hispanic

21

1.12

6*

0.34*

27

0.74

Poisoning deaths

White

24

0.28

12*

0.15*

36

0.22

Black

9*

0.50*

9*

0.51*

18*

0.51*

American Indian/Alaskan Native

2*

1.30*

1*

0.67*

3*

0.99*

Asian Pacific Islander

1*

0.22*

3*

0.69*

4*

0.44*

All races, Non-Hispanic

33

0.37

20*

0.23*

53

0.30

All races, Hispanic

3*

0.16*

5*

0.28*

8*

0.22*

Suicide deaths

White

147

1.74

41

0.51

188

1.14

Black

34

1.88

9*

0.51*

43

1.21

American Indian/Alaskan Native

6*

3.91*

1*

0.67*

7*

2.31*

Asian Pacific Islander

1*

0.22*

5*

1.14*

6*

0.67*

All races, Non-Hispanic

156

1.74

44

0.51

200

1.14

All races, Hispanic

31

1.66

12*

0.67*

43

1.18

Homicide deaths

White

72

0.85

26

0.32

98

0.60

Black

66

3.65

29

1.66

95

2.67

American Indian/Alaskan Native

1*

0.65*

1*

0.67*

2*

0.66*

Asian Pacific Islander

6*

1.29*

1*

0.23*

7*

0.78*

All races, Non-Hispanic

116

1.29

49

0.57

165

0.94

All races, Hispanic

29

1.55

8*

0.45*

37

1.01

TABLE 5.12Crude Death Rates (per 100,000) and Number of Deaths Due to All Intent Injuries among Adolescents 15- to 19-Year-Olds by Event, Race, Ethnicity (Hispanic, Non-Hispanic), and Sex, United States, 2003

Male

Female

Both

Race

No.

Rate

No.

Rate

No.

Rate

a Rates based on 20 or fewer deaths may be unstable. Use with caution.Adapted the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, WISQARS, United States, Injury mortality reports. Available at: www.cdc.gov/ncipc/osp/data.htm. 2003.

All injury deaths

White

5,830

70.41

2,173

27.86

8,003

49.77

Black

1,580

96.78

300

18.94

1,880

58.44

American Indian/Alaskan Native

163

109.14

73

50.71

236

80.46

Asian Pacific Islander

175

38.01

75

17.20

250

27.89

All races, Non-Hispanic

6,367

72.02

2,276

27.09

8,643

50.12

All races, Hispanic

1,350

80.23

339

21.71

1,689

52.06

All injury and adverse effects deaths

White

5,845

70.59

2,176

27.90

8,021

49.88

Black

1,582

96.90

300

18.94

1,882

58.51

American Indian/Alaskan Native

164

109.81

73

50.71

237

80.80

Asian Pacific Islander

175

38.01

75

17.20

250

27.89

All races, Non-Hispanic

6,382

72.19

2,278

27.11

8,660

50.22

All races, Hispanic Cut/pierce deaths

1,352

80.35

340

21.77

1,692

52.16

White

71

0.86

15*

0.19*

86

0.53

Black

62

3.80

18*

1.14*

80

2.49

American Indian/Alaskan Native

6*

4.02*

1*

0.69*

7*

2.39*

Asian Pacific Islander

4*

0.87*

1*

0.23*

5*

0.56*

All races, Non-Hispanic

104

1.18

28

0.33

132

0.77

All races, Hispanic

36

2.14

7*

0.45*

43

1.33

Drowning deaths

White

194

2.34

18*

0.23*

212

1.32

Black

58

3.55

4*

0.25*

62

1.93

American Indian/Alaskan Native

3*

2.01*

1*

0.69*

4*

1.36*

Asian Pacific Islander

18*

3.91*

1*

0.23*

19*

2.12*

All races, Non-Hispanic

224

2.53

23

0.27

247

1.43

All races, Hispanic

46

2.73

1*

0.06*

47

1.45

Fall deaths

White

82

0.99

23

0.29

105

0.65

Black

8*

0.49*

2*

0.13*

10*

0.31*

American Indian/Alaskan Native

2*

1.34*

2*

1.39*

4*

1.36*

Asian Pacific Islander

6*

1.30*

1*

0.23*

7*

0.78*

All races, Non-Hispanic

86

0.97

27

0.32

113

0.66

All races, Hispanic

12*

0.71*

1*

0.06*

13*

0.40*

Fire/burn deaths

White

44

0.53

27*

0.35*

71

0.44

Black

13*

0.08*

11*

0.69*

24

0.75

American Indian/Alaskan Native

0*

0*

1*

0.69*

1*

0.34*

Asian Pacific Islander

2*

0.43*

0*

0*

2*

0.22*

All races, Non-Hispanic

49

0.55

35

0.42

84

0.49

All races, Hispanic

10*

0.59*

4*

0.26*

14*

0.43*

Residential fire/flame deaths

White

27

0.33

16*

0.21*

43

0.27

Black

9*

0.55*

10*

0.63*

19*

0.59*

American Indian/Alaskan Native

0*

0*

1*

0.69*

1*

0.34*

Asian Pacific Islander

1*

0.22*

0*

0*

1*

0.11*

All races, Non-Hispanic

32

0.36

24

0.29

56

0.32

All races, Hispanic

5*

0.30*

3*

0.19*

8*

0.25*

Firearm deaths

White

1,194

14.42

154

1.97

1,348

8.38

Black

969

59.35

67

4.23

1,036

32.21

American Indian/Alaskan Native

34

22.77

9*

6.25*

43

14.66

Asian Pacific Islander

34

7.39

8*

1.83*

42

4.69

All races, Non-Hispanic

1,766

19.98

193

2.30

1,959

11.36

All races, Hispanic

454

26.98

44

2.82

498

15.35

Motor vehicle, overall

White

2,996

36.18

1,532

19.64

4,528

28.16

Black

352

21.56

145

9.15

497

15.45

American Indian/Alaskan Native

78

52.53

43

29.87

121

41.25

Asian Pacific Islander

86

18.68

50

11.47

136

15.17

All races, Non-Hispanic

2,925

33.09

1,546

18.40

4,471

25.93

All races, Hispanic

580

34.47

221

14.15

801

24.69

Motorcyclist deaths

White

157

1.90

17*

0.22*

174

1.08

Black

12*

0.74*

2*

0.13*

14*

0.44*

American Indian/Alaskan Native

1*

0.67*

0*

0*

1*

0.34*

Asian Pacific Islander

4*

0.87*

1*

0.23*

5*

0.56*

All races, Non-Hispanic

147

1.66

19*

0.23*

166

0.96

All races, Hispanic

27

1.60

1*

0.06*

28

0.86

Pedal cyclist deaths

White

40

0.48

12*

0.15*

52

0.32

Black

7*

0.43*

0*

0*

7*

0.22*

American Indian/Alaskan Native

4*

2.68*

0*

0*

4*

1.38*

Asian Pacific Islander

2*

0.43*

0*

0*

2*

0.22*

All races, Non-Hispanic

45

0.51

10*

0.12*

55

0.32

All races, Hispanic

8*

0.48*

2*

0.13*

10*

0.31*

Pedestrian deaths

White

178

2.15

82

1.05

260

1.62

Black

37

2.27

19*

1.20*

56

1.74

American Indian/Alaskan Native

14*

9.37*

4*

2.78*

18*

6.14*

Asian Pacific Islander

6*

1.30*

3*

0.69*

9*

1*

All races, Non-Hispanic

182

2.06

91

1.08

273

1.58

All races, Hispanic

53

3.15

17*

1.09*

70

2.16

Poisoning deaths

White

499

6.03

180

2.31

679

4.22

Black

14*

0.86*

13*

0.82*

27

0.84

American Indian/Alaskan Native

8*

5.36*

4*

2.78*

12*

4.09*

Asian Pacific Islander

5*

1.09*

2*

0.46*

7*

0.78*

All races, Non-Hispanic

463

5.24

179

2.13

642

3.72

All races, Hispanic

62

3.68

19*

1.22*

81

2.50

Suicide deaths

White

1,047

12.64

227

2.91

1,274

7.92

Black

107

6.55

14*

0.88*

121

3.76

American Indian/Alaskan Native

37

24.77

13*

9.03*

50

17.05

Asian Pacific Islander

31

6.73

11*

2.52*

42

4.69

All races, Non-Hispanic

1,065

12.05

227

2.70

1,292

7.49

All races, Hispanic

155

9.21

37

2.37

192

5.92

Homicide deaths

White

660

7.97

138

1.77

798

4.96

Black

962

58.92

106

6.69

1,068

33.20

American Indian/Alaskan Native

23

15.40

8*

5.56*

31

10.57

Asian Pacific Islander

32

6.95

9*

2.06*

41

4.57

All races, Non-Hispanic

1,239

14.02

212

2.52

1,451

8.41

All races, Hispanic

423

25.14

48

3.07

471

14.52

TABLE 5.13Crude Death Rates (per 100,000) and Number of Deaths Due to All-Intent Injuries among Adolescents 20- to 24-Year-Old by Event, Race, Ethnicity (Hispanic, Non-Hispanic), and Sex, United States, 2003

Male

Female

Both

Race

No.

Rate

No.

Rate

No.

Rate

a Rates based on 20 or fewer deaths may be unstable. Use with caution.Adapted from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, WISQARS (Web-based Injury Statistics Query and Reporting System), United States, Injury mortality reports. Available at: www.cdc.gov/ncipc/osp/data.htm. 2003.

All injury deaths

White

8,779

103.69

2,240

28.43

11,019

67.41

Black

2,797

180.37

480

30.74

3,277

105.30

American Indian/Alaskan Native

213

148.83

58

43.77

271

98.32

Asian Pacific Islander

261

49.93

88

17.19

349

33.73

All races, Non-Hispanic

9,830

114.15

2,498

29.69

12,328

72.42

All races, Hispanic

2,179

105.19

354

21.16

2,533

67.65

All injury and adverse effects deaths

White

8,786

103.77

2,252

28.58

11,038

67.53

Black

2,798

180.43

483

30.93

3,281

105.42

American Indian/Alaskan Native

213

148.83

58

43.77

271

98.32

Asian Pacific Islander

261

49.93

88

17.19

349

33.73

All races, Non-Hispanic

9,837

114.23

2,512

29.86

12,349

72.54

All races, Hispanic Cut/pierce deaths

2,180

105.23

355

21.22

2,535

67.70

White

133

1.57

43

0.55

176

1.08

Black

100

6.45

31

1.99

131

4.21

American Indian/Alaskan Native

8*

5.59*

2*

1.51*

10*

3.63*

Asian Pacific Islander

13*

2.49*

2*

0.39*

15*

1.45*

All races, Non-Hispanic

179

2.08

59

0.70

238

1.40

All races, Hispanic

75

3.62

18*

1.08*

93

2.48

Drowning deaths

White

222

2.62

22

0.28

244

1.49

Black

50

3.22

5*

0.32*

55

1.77

American Indian/Alaskan Native

8*

5.59*

0*

0*

8*

2.90*

Asian Pacific Islander

19*

3.63*

4*

0.78*

23

2.22

All races, Non-Hispanic

229

2.66

28

0.33

257

1.51

All races, Hispanic

70

3.38

3*

0.18*

73

1.95

Fall deaths

White

158

1.87

28

0.36

186

1.14

Black

14*

0.90*

6*

0.38*

20*

0.64*

American Indian/Alaskan Native

3*

2.10*

1*

0.75*

4*

1.45*

Asian Pacific Islander

6*

1.15*

3*

0.59*

9*

0.87*

All races, Non-Hispanic

144

1.67

33

0.39

177

1.04

All races, Hispanic

37

1.79

5*

0.30*

42

1.12

Fire/burn deaths

White

78

0.92

50

0.63

128

0.78

Black

16*

1.03*

10*

0.64*

26

0.84

American Indian/Alaskan Native

3*

2.10*

0*

0*

3*

1.09*

Asian Pacific Islander

0*

0*

2*

0.39*

2*

0.19*

All races, Non-Hispanic

88

1.02

54

0.64

142

0.83

All races, Hispanic

8*

0.39*

8*

0.48*

16*

0.43*

Residential fire/flame deaths

White

45

0.53

31

0.39

76

0.46

Black

8*

0.52*

7*

0.45*

15*

0.48*

American Indian/Alaskan Native

1*

0.70*

0*

0*

1*

0.10*

Asian Pacific Islander

0*

0*

1*

0.20*

1*

0.10*

All races, Non-Hispanic

52

0.60

36

0.43

88

0.52

All races, Hispanic

2*

0.10*

3*

0.18*

5*

0.13*

Firearm deaths

White

2,022

23.88

240

3.05

2,262

13.84

Black

1,817

117.17

164

10.50

1,981

63.65

American Indian/Alaskan Native

47

32.84

6*

4.53*

53

19.23

Asian Pacific Islander

69

13.20

12*

2.34*

81

7.83

All races, Non-Hispanic

3,159

36.68

350

4.16

3,509

20.61

All races, Hispanic

780

37.65

68

4.07

848

22.65

Motor vehicle, overall

White

3,586

42.35

1,167

14.81

4,753

29.08

Black

538

34.69

157

10.05

695

22.33

American Indian/Alaskan Native

99

69.18

35

26.41

134

48.62

Asian Pacific Islander

96

18.36

42

8.21

138

13.34

All races, Non-Hispanic

3,488

40.5

1,232

14.65

4,720

27.73

All races, Hispanic

820

39.58

165

9.86

985

26.31

Motorcyclist deaths

White

396

4.68

37

0.47

433

2.65

Black

50

3.22

3*

0.19*

53

1.70

American Indian/Alaskan Native

3*

2.10*

0*

0*

3*

1.09*

Asian Pacific Islander

17*

3.25*

0*

0*

17*

1.64*

All races, Non-Hispanic

415

4.82

37

0.44*

452

2.66

All races, Hispanic

50

2.41

3*

0.18*

53

1.42

Pedal cyclist deaths

White

31

0.37

0*

0*

31

0.19

Black

2*

0.13*

2*

0.13*

4*

0.13*

American Indian/Alaskan Native

0*

0*

0*

0*

0*

0*

Asian Pacific Islander

1*

0.19*

0*

0*

1*

0.10*

All races, Non-Hispanic

22

0.26

2*

0.02*

24

0.14

All races, Hispanic

12*

0.58*

0*

0*

12*

0.32*

Pedestrian deaths

White

246

2.91

72

0.91

318

1.95

Black

46

2.97

16*

1.02*

62

1.99

American Indian/Alaskan Native

12*

8.38*

1*

0.75*

13*

4.72*

Asian Pacific Islander

8*

1.53*

5*

0.98*

13*

1.26*

All races, Non-Hispanic

232

2.69

84

1

316

1.86

All races, Hispanic

77

3.72

10*

0.60*

87

2.32

Poisoning deaths

White

1,408

16.63

441

5.60

1,849

11.31

Black

70

4.51

25

1.60

95

3.05

American Indian/Alaskan Native

13*

9.08*

4*

3.02*

17*

6.17*

Asian Pacific Islander

13*

2.49*

11*

2.15*

24

2.32

All races, Non-Hispanic

1,354

15.72

442

5.25

1,796

10.55

All races, Hispanic

148

7.14

38

2.27

186

4.97

Suicide deaths

White

1,781

21.04

263

3.34

2,044

12.50

Black

278

17.93

48

3.07

326

10.47

American Indian/Alaskan Native

43

30.05

10*

7.55*

53

19.23

Asian Pacific Islander

57

10.90

21

4.10

78

7.54

All races, Non-Hispanic

1,885

21.89

306

3.64

2,191

12.87

All races, Hispanic

266

12.84

33

1.97

299

7.99

Homicide deaths

White

1,121

13.24

252

3.2

1,373

8.40

Black

1,727

111.37

211

13.51

1,938

62.27

American Indian/Alaskan Native

35

24.46

12*

9.06*

47

17.05

Asian Pacific Islander

64

12.24

8*

1.56*

72

6.96

All races, Non-Hispanic

2,216

25.73

378

4.49

2,594

15.24

All races, Hispanic

716

34.56

99

5.92

815

21.77

TABLE 5.14Unintentional Injury Mortality Rates (per 100,000 and Number of Deaths by Age Group), United States, 1979, 1996, and 2003

1979

1996

2004

Age Group

Rate

Number

Rate

Number

Rate

Number

Adapted from The National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, WISQARS. United States, 2004. Injury mortality reports. Available at: www.cdc.gov/ncipc/osp/data.htm. Last accessed 12.4.2006.

0–4

27.24

4,377

15.01

2,895

13.42

2,693

5–9

15.97

2,690

8.04

1,564

5.74

1,126

10–14

16.07

2,966

9.61

1,824

7.29

1,540

15–19

59.30

12,664

36.09

6,735

32.93

6,825

All children and adolescents

31.16

22,697

17.04

13,018

14.94

12,184

Gender:

A second important risk factor for injury is gender. Beginning at approximately 1 or 2 years of age and continuing until the seventh decade of life, males have higher rates of injury than females. This gender difference during childhood does not appear to be caused by differences in developmental or motor skills. In part, it may be related to greater exposure of males to hazards or to gender-based differences in behavior (Rivara and Aitken, 1998). For nearly all injuries in 2003, the male death rate from injuries exceeds the rate in females: 2.1 times among adolescents aged 10 to 14 years, 2.8 times for ages 15 to 19 years, and 3.97 times for young adults aged 20 to 24 years (National Center for Injury Prevention and Control, 2006b).

TABLE 5.15Unintentional Injury Death Rates (per 100,000) among Youth by Age Group, United States, 1903–2003

Injury death rates also vary substantially by race and ethnicity. The highest injury fatality rates are among African-American and Native American adolescents and the lowest rates are among Asian youth, as seen in Tables 5.11, 5.12, and 5.13. In 2003, adolescent African-American males had the highest death rates due to drowning, firearms, and homicide. Although the overall numbers are lower, American Indian and Alaskan Natives have the highest overall death rates among 10- to 19-year olds and the second highest among 20- to 24-year olds. African-American males had the highest death rate among 20- to 24-year olds. Hispanic youth have rates between those of whites and African-Americans, although age and gender also influence those rates. A further explanation for these racial differences appears to be related to poverty, which is another important risk factor in predicting adolescent injuries.

Factors Contributing to Adolescent Injuries

Socioeconomic factors:

Poor children are at greatest risk for injury and studies have indicated that their risk level is two to five times that of children who are not poor. This is true for pedestrian injuries, fires and burns, drownings, and intentional injuries. The number of U.S. children living in poverty in 2003 was 12.7 million (Annie E. Casey Foundation, 2005). The injury death rate is consistently higher in nonmetropolitan areas than in cities (Rivara and Aitken, 1998).

Environmental factors:

The risk associated with each type of adolescent injury is also influenced by environmental factors. These include hazards such as all-terrain vehicles, backyard swimming pools, firearms, kerosene

Because children and adolescents spend much of their day at school, it follows that many of the injuries they sustain occur there. In fact, between 33% and 50% of all child and adolescent injuries happen on school grounds. Playground accidents are the most common source of childhood injury at schools, particularly in the lower grades. However, most such injuries are minor and do not require medical attention (Hudson et al., 1999). Males are injured at school much more often than females. Falls are the most common cause of injury in secondary schools, and they usually result in contusions, abrasions, or local swelling. Also frequent are burns, strains, sprains, and dislocations, especially of the upper extremities. The number of injuries that occur in vocational classrooms and on athletic fields increases with age and grade level. A large number of those injuries involve the improper use or malfunctioning of equipment (Knight et al., 2000).

Developmental factors:

Factors contributing to high injury rates in adolescents often relate to the discrepancies between an adolescent's physical development and his or her cognitive and emotional development. Adolescent health is influenced by the strengths and vulnerabilities of individuals and also by the character of the settings in which they live. These settings—the schools they attend, the neighborhoods they call home, their families, and the friends who make up their social network—play an important role in shaping adolescent health, affecting how individuals feel about themselves as well as influencing the choices they make about behaviors that can affect their health and well-being.

As a group, adolescents are physically healthy. They have survived early childhood and are decades away from the diseases associated with aging. Threats to their health stem primarily from their behavior. Several developmental characteristics of the adolescent contribute to risk-taking behaviors and may lead to injuries and death. Some of these characteristics are as follows:

Experimentation with adult roles

Experimentation with risky behaviors or situations when opportunities for healthy risk taking are not available or provided

Challenge of authority or rules

Desire for peer approval and a tendency to join peer activities and to follow peer norms

Placing these characteristics in an environment where there is alcohol, tobacco, violence, unprotected sex, fast cars, and drugs heightens adolescents' risk of injury and death (Blum and Rinehart, 1999).

Automobile injuries

Automobile injuries are the leading cause of mortality and morbidity among all Americans aged 1 to 64 years. The transportation environment is the most dangerous setting for the adolescent, whether as a driver, passenger, motorcyclist, bicyclist, or pedestrian. Crashes involving adolescent drivers typically are single-vehicle crashes, primarily run-off-the-road crashes, and involve driver error and/or speeding (Insurance Institute for Highway Safety, 2005). Among youth 10- to 19-years old, motor vehicle traffic–related injuries account for almost 36% of all deaths and 74% of deaths due to unintentional injuries (National Center for Injury Prevention and Control, 2006a). An excellent overall review of the teen driver is in the American Academy of Pediatrics policy statement from December 2006. This policy paper reviews risk factors, proposed interventions, and recommendations for health care providers.

Risk Factors for Automobile Injuries

Teenagers are at particularly high risk for motor vehicle crashes primarily because of their inexperience and risk-taking behaviors. Teenagers are more likely to underestimate the dangers in hazardous situations, and have less experience coping with such situations (Chen et al., 2000; Insurance Institute for Highway Safety, 2005). Research shows that teenagers are more likely than older drivers to speed, run red lights, make illegal turns, tailgate, ride with an intoxicated driver, and drive after using alcohol or other drugs. Males are more likely than females to engage in risky driving behaviors, drive after drinking alcohol, and are less likely to wear seat belts (Centers for Disease Control and Prevention, 2006). Younger age, driving at night, having other teen passengers in the vehicle, and driving after drinking alcohol increases the risk of motor vehicle crashes.

More than 75% of children aged 5 to 14 years who die in traffic crashes were not wearing a seat belt or other restraint (Federal Interagency Forum on Child and Family Statistics, 2000).

In 2003, two out of every three adolescents killed in motor vehicle crashes were male.

The risk of crash involvement per mile driven among drivers aged 16 to 19 years is four times the risk among older drivers.

Approximately 60% of adolescent passenger deaths in 2003 were in motor vehicles driven by another adolescent.

In 2001 to 2002, night time passenger vehicle crashes were three times higher among females and six times higher among male drivers 16- to 19-years old than for those 30- to 59-years old.

The incidence of motor vehicle crashes fatal to 16- and 17- year-old drivers, in particular, increases with the number of passengers for both male and female drivers, during daytime and at night. Crashes are more likely to be fatal to drivers aged 16 and 17 years when in the presence of male passengers, teenage passengers, and passengers aged 20 to 29 years (Chen et al., 2000).

Alcohol

Alcohol involvement in crashes is highest among men aged 21 to 30 years. Alcohol-related crashes peak at night and are higher on weekends than on weekdays. Among passenger vehicle drivers fatally injured between 9 p.m. and 6 a.m. in 1998, 55% had a blood alcohol concentration (BAC) of 0.10% or greater, compared with 15% of such drivers during other hours. On weekends in 1998 (6 p.m. Friday to 6 a.m.

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Monday) 41% of fatally injured drivers had a BAC of 0.10% or higher; during the week, the corresponding measure was 21% (Insurance Institute for Highway Safety, 2005a).

Data analysis shows that at all levels of BAC, the risk of being involved in a motor vehicle crash is greater for teenagers and young people than for older people. In 2003, 16% of fatally injured drivers aged 16 and 17 had BACs at or >0.08%, a 60% decrease from 1982 (Insurance Institute for Highway Safety, 2005a). Teenage male drivers with a BAC in the 0.5% to 0.10% range are 18 times more likely and female drivers 54 times more likely than sober teenagers to be killed in single-vehicle crashes (Insurance Institute for Highway Safety, 2005). Although many states have reduced the BAC for “driving while intoxicated” (DWI) convictions to 0.08%, zero-tolerance policies for adolescents younger than 21 years may further reduce alcohol-related motor vehicle injuries.

In a 2005 national survey of high school students, 28.5% of respondents said that within the last 30 days they had ridden in a motor vehicle driven by someone who had been drinking alcohol (Centers for Disease Control and Prevention, 2006) and 9.9% had driven a motor vehicle after drinking alcohol. This is a decrease from 39.9% and 16.7%, respectively, in 1991.

Air Bags and Seat Belts

For all ages, air bags reduce the risk of death in frontal crashes by 18% and in all crashes by 11%. However, for children younger than 13 years air bags actually may increase the risk of death. A safety device that protects against death in all but a very few specific situations is the safety belt, with which all vehicles are equipped (Rivara, 1999). In the 2005 YRBS, approximately 10% of high school students reported that they rarely or never wear safety belts when riding with someone else (Centers for Disease Control and Prevention, 2006). Male high school students are more likely (12.5%) than female students (7.8%) to rarely or never wear safety belts. Black (13.4%) and Hispanic (10.6%) students are more likely than white students (9.4%) to rarely or never wear safety belts (Centers for Disease Control and Prevention, 2006).

Graduated Licensing Programs

Motor vehicle crashes are highest in the first 2 years that drivers have their license. The crash rate per mile driven is twice as high among 16-year olds as it is among 18- to 19-year olds. Graduated licensing programs are ideally designed to have three phases of supervision including a supervised learning period, an intermediate restricted license, and then an unrestricted license. In the intermediate phase, new drivers have limits on higher risk conditions such as late-night driving and transporting other adolescent passengers while unsupervised. After this phase, the restrictions are removed and the driver is fully licensed. Early data from states that have implemented graduated driving demonstrate a decrease in adolescent motor vehicle–related crashes and fatalities (Marin and Brown, 2005; Hedlund and Compton, 2005). Almost all states have enacted some form of a graduated driver licensing law.

Nonautomobile Injuries

Motorcycle

Males accounted for nine of every ten motorcycle deaths in 2005.

A total of 4,439 motorcyclists died in crashes in 2005. Motorcyclist deaths had been declining since the early 1980s but began to increase in 1998 and have continued to increase. Since 1997 motorcyclist deaths have more than doubled.

In 2005, 32% of all motorcycle deaths occurred among 16- to 29-year olds.

For each mile traveled, the number of deaths on motorcycles is 27 times greater than in cars (Insurance Institute for Highway Safety, 2005b).

Drowning

Drowning was the second leading cause of unintentional death in children younger than 15 and the third cause of unintentional death in those 15- to 24-years old in 2004. Approximately 1,500 children and adolescents die each year in the United States (Rivara, 1999). Drowning is unique as an injury problem because of its high case-fatality rate and because of the relative lack of impact that medical care has on outcome. Approximately 50% of children and adolescents requiring care for a submersion incident will die (Rivara, 1999). Swimming pools play a role in drowning among young, school-aged children and among adolescents; immersion in natural bodies of water, either while swimming or boating, also plays an increasingly important role (Rivara and Aitken, 1998).

Gender:

In 2004, males accounted for almost 80% of fatal drownings in the United States. Males are three times more likely to die from drowning than are females in almost every age-group (National Center for Injury Prevention and Control, 2006c). Males between the ages of 15 and 19 years are more than 10 times likely to drown than females of the same age.

Race:

In 2004, the overall age-adjusted drowning rate for African-Americans was 1.25 times higher than that for whites. Black children aged 5 to 19 years drowned at 2.3 times the rate of similar-aged whites.

Alcohol use:

Alcohol use is involved in approximately 25% to 50% of adolescent and adult deaths associated with water recreation. It is also a major contributing factor in up to 50% of drownings among adolescent boys in particular (National Center for Injury Prevention and Control, 2006c).

Firearms

Firearms are the sixth leading cause of death due to unintentional injuries in the adolescent age-group. In 2004, 3,635 children and adolescents 20 years and younger died from firearms. This represents an 11% reduction from 1997 and a 47% decrease since 1994. Tables 5.11, 5.12, and 5.13 include the number of death and mortality rates by firearms according to age-group, sex, and race in 2003.

It is estimated that there are three nonfatal firearm injuries for every death associated with a firearm.

Adolescents and young adults have the highest rate of unintentional firearm-related fatalities; males between the ages of 20 and 24 years having the highest risk (National Center for Health Statistics, 2006a).

More than 75% of homicides of older adolescents and young adults are committed with a firearm.

Among adolescents 15- to 19-years old, one in every four deaths is caused by a firearm (National Center for Injury Prevention and Control, 2006a).

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More than 85% of all firearm-related deaths occur in males (Rivara, 1999).

Firearm assaults on family members and other intimate acquaintances are 12 times more likely to result in death than assaults with other weapons.

In 2005, 5.4% of high school students in a national survey reported having carried a gun to school within the last 30 days (Centers for Disease Control and Prevention, 2006).

Bicycle Accidents

In 2005, 782 bicyclists were killed in crashes with motor vehicles. This is a 38% reduction since 1975 but a 25% increase since 2003.

In 2005, 21% of bicycle deaths were among riders 14 years and younger (National Highway Traffic Safety Administration, 2005).

In 2005, 87% of bicycle deaths occurred among males (IIHS 2005c).

In 2005, 23% of riders who died in a bicycle-related accident had elevated blood alcohol levels.

Bicycle deaths are most likely to occur in the summer and fall and between the hours of 3 p.m. and 9 p.m. (IIHS, 2005c).

In 2002, almost 300,000 children 14 years and younger were treated in emergency departments for bicycle-related injuries.

Approximately 70% of fatal bicycle crashes involve head injuries.

In 2005, 86% of bicycle-related deaths occurred in riders without helmets (Insurance Institute for Highway Safety 2005c). Bicycle helmets decrease the risk of head injury by 85% and brain injury by 88%.

Collisions with motor vehicles are responsible for approximately 33% of all bicycle-related brain injuries and 90% of bicycle fatalities.

In 2005, of all high school students who reported riding a bicycle within the preceding 12 months, 83.4% reported never or rarely wearing a bicycle helmet (Centers for Disease Control and Prevention, 2006).

Skateboards

Skateboarding has experienced intermittent periods of popularity since the 1960s. Along with this popularity, there have been concomitant increases in numerous types of injuries. Most documented cases occur in boys between the ages of 10 and 14 years, with injuries ranging from minor cuts and abrasions to multiple fractures and, in some cases, even death. Head injuries account for approximately 3.5% to 9% and fractures of both upper and lower extremities account for 50% of all skateboarding injuries. Not surprisingly, 33% of those injured on skateboards experience some form of trauma within the first week of participating in the sport. Despite traffic legislation, 65% of injured adolescents sustain injuries on public roads, footpaths, and parking lots (Fountain and Meyers, 1996).

All-Terrain Vehicles

Almost 3,000 deaths have been associated with use of allterrain vehicles (ATVs) since 1985. The risk of death is approximately 0.8 to 1.0/10,000 ATVs, and has remained fairly steady for the last 10 years. Children younger than 16 years account for 47% of the injuries and 36% of deaths, whereas those younger than 12 years represent 15% of all deaths related to ATVs. Risk factors for injury include rider inexperience, intoxication with alcohol, excessive speed, and lack of helmet use. Head injuries account for most ATV-related deaths. Other nonfatal injuries include head and spinal trauma, abdominal injuries, abrasions, lacerations, and fractures (American Academy of Pediatrics, Committee on Injury and Poison Prevention, 2000a).

Boating Accidents

In 2004, the U.S. Coast Guard received reports for 4,904 boating incidents; 3,363 participants were reported injured and 676 died in boating incidents (National Center for Injury Prevention and Control, 2006c). Among those who drowned, 90% were not wearing life jackets. Most boating fatalities in 2004 (70%) were caused by drowning; the remainder were due to trauma, hypothermia, carbon monoxide poisoning, or other causes. Alcohol was involved in about one third of all reported boating fatalities. Personal watercrafts (PWCs) were involved in 25% of incidents.

The use of PWC has increased dramatically during the last decade, as have the speed and mobility of the watercraft. A similar dramatic increase in PWC-related injury and death has occurred simultaneously. In many states, persons younger than 16 years are not legal operators of PWCs. Nonetheless, 7% of these injuries occur in children aged 14 years and younger and 27% occur in those younger than 17 years. The most common types of PWC-related injuries are head trauma, lacerations, and fractures (American Academy of Pediatrics, Committee on Injury and Poison Prevention, 2000b).

Poisoning

In 2004 alone, more than 2.4 million human exposures to poison were reported to poison control centers in the United States (Watson et al., 2005). U.S. poison centers handled one poison exposure every 13 seconds. Each year, almost 900,000 visits to emergency departments occur because of poisonings (National Center for Injury Prevention and Control, 2006c). Although young children are at particularly high risk for unintentional ingestion, the percentage of unintentional deaths due to poisoning actually increases with age in the adolescent population (National Center for Injury Prevention and Control, 2006b). Adolescent females are more likely to die by poisoning compared to males (55.1% vs. 44.5%). In 2004, there were 90 reported adolescent fatalities, comprising 7.6% of all poison-related fatalities. Of these, >50% were presumed suicides and 27% were caused by intentional abuse (Watson et al., 2005).

Common household items are often the cause of poisonings. For young adolescents between the ages of 10 and 14 years, approximately 80% of all poisoning deaths are from substances other than medications. In contrast, medications cause 58% of all poisoning deaths among adolescents aged 15 to 19 years. The most lethal substances for children of all ages are stimulants, street drugs, cardiovascular drugs, and antidepressants (Grossman, 2000b).

Sports Injuries

In the 2004–2005 school year, the number of high school athletes increased to more than 7 million participants. This is the 16th consecutive year of increased participation (National Federation of State High School Associations, 2005). Such participation also results in approximately 750,000

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sports-related injuries each year that require hospital-based emergency treatment. In total, injury rates are reported to be as high as 81% of all participants, with >3 million injuries annually resulting in time lost from sports (Marsh and Daigneault, 1999). Football is associated with the highest number of catastrophic (fatal, permanent severe functional disability, or severe injury without permanent functional disability) injuries. Male athletes account for 84% of all adolescent sports-related injuries, despite the fact that rates are often higher among females, because fewer girls participate overall (Cheng et al., 2000). However, the number of catastrophic injuries among female athletes has increased. According to the National Center for Catastrophic Sports Injury Research, the incorporation of gymnastic type stunts in cheerleading has lead to these sports accounting for 50% of high school and 64% of college female athlete catastrophic injuries (National Center for Catastrophic Sport Injury Research, 2005). Within any given season, it is estimated that 48% of all adolescent athletes sustain at least one injury (Patel and Nelson, 2000). Of all adolescent sports injuries, 17% occur while participating in one of six sports—football, basketball, baseball or softball, soccer, biking, or skating. The event-based injury rate is 25.0 per 1,000 adolescents and the most common mechanisms are falls and being struck by or against objects. Table5.16 shows the percentages of injury types and body locations in those six high school sports. Hospitalization is required in 2% of all sports-related injury visits; of those cases, 51% involve other persons, 12% are equipment related, and 8% involve poor field or surface conditions (Cheng et al., 2000).

TABLE 5.16Injuries in Six Sports: Injury Type and Body Location, 1996–1998 (percentage with each sport)

Football accounts for the highest number of injuries in boys (Patel and Nelson, 2000). Of all football injuries, 7% involve being struck by an opponent's helmet and 9% involve inappropriate field conditions. Football has the highest number and rate of mild traumatic brain injury. The chance of sustaining a mild brain injury is 11 times higher during football games than during practices (Powell and Barber-Foss, 1999). In 2004, there were 19 high school and ONE college catastrophic injuries (National Center for Catastrophic Sport Injury Research, 2005). In addition, there were ten indirect fatalities related to heat stroke and lightning strikes. There were also 13 permanent disabilities—10 cervical spine and 3 head injuries.

Basketball

Basketball causes more facial and dental injuries among adolescents than any other sport (American Academy of Pediatrics, Committee on Sports Medicine and Fitness CSMF, 2000a). The injury rates for boys' and girls' basketball are 28.3 and 28.7 per 100 players, respectively. For both boys and girls, the ankle or foot is the most common site of injury, accounting for 39.3% of injuries in boys and 36.6% in girls. Knee injuries make up 11.1% of all injuries in boys and 15.7% in girls. Boys sustain 42% of their injuries in game situations, whereas 46.8% of girls' injuries happen during games. The types of activities that mostly cause injury during games are dribbling for girls (13.1%) and shooting or related activities for boys (13.3%) (Powell and Barber-Foss, 2000).

Baseball

The adolescent injury rate for baseball is 13.2 per 100 players. Of all baseball injuries, 55% involve ball or bat impact, often to the head (Cheng et al., 2000). Baseball injuries are divided fairly evenly between practices and games. During baseball games, base running accounts for the largest proportion of injuries (25.7%), followed by fielding (23.4%). Approximately 24.6% of baseball injuries occur to the forearm, wrist, or hand, and 19.7% occur to the arms or shoulders. Approximately one in five baseball injuries occur among pitchers (Powell and Barber-Foss, 2000).

Softball

The adolescent injury rate for softball is 16.7 per 100 players. This makes the softball injury rate 27% higher than that of baseball. Practices account for 55.9% of all softball injuries. The types of softball injuries that occur most often are similar to those that occur in baseball. During softball games, base running accounts for the largest proportion of injuries (32.7%), followed by fielding (26.9%). Slightly >10% of softball injuries occur among pitchers. Approximately 22.9% of softball injuries occur to the forearm, wrist, or hand, and 16.3% occur to the arms or shoulders (Powell and Barber-Foss, 2000).

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Soccer

Soccer is one of the most popular team sports. Of all soccer-related injuries, 45% occur in players younger than 15 years. Injury rates per 1,000 player-hours range from 0.6 to 19.1 per 1,000, depending on the level of play and the definition of injury. Soccer is the second leading cause of facial and dental injuries in sports, preceded only by basketball (American Academy of Pediatrics, Committee on Sports Medicine and Fitness, 2000a). For all sports, soccer accounts for the highest number of injuries in girls (Patel and Nelson, 2000). The injury rates for boys' and girls' soccer are 23.4 and 26.7 per 100 players, respectively. Most soccer injuries happen during game situations, accounting for 59.3% of boys' injuries and 57.8% of girls' injuries. The most common site of soccer injury for both boys and girls is the ankle or foot, accounting for 33.3% of boys' injuries and 33.5% of girls' injuries. Other injuries occur most commonly to the hip, thigh, or leg and then the knee, for both boys and girls. Concussive injuries during soccer often occur because of head–head or head–ground impact (National Center for Catastrophic Sport Injury Research, 2004). The knee injury rate for girls' soccer is 5.2 per 100 players (Powell and Barber-Foss, 2000). In 1999, the Consumer Product Safety Commission announced new safety standards to reduce the risk of soccer goal tip-over. Tip-overs have been associated with a number of soccer participant fatalities (National Center for Catastrophic Sport Injury Research, 2005).

Ice Hockey

Ice hockey is played by approximately 200,000 youth in the United States. Because collisions in this sport occur at high speeds, participants are at risk for serious injury. Among players between the ages of 9 and 15 years, head and neck trauma account for 23% of all injuries. Body checking accounts for 86% of all injuries that occur during games. Of particular concern is that size differences among players often increase with age, with 14- and 15-year-old players showing the most variation. Players in this age-group also sustain the most injuries (54%) (American Academy of Pediatrics, Committee on Sports Medicine and Fitness, 2000b).

Recovery from Injuries: Considerations in the Adolescent

Children and youth grow and mature both physically and psychologically during the adolescent years. Maturation results in physiological changes that affect performance, health status, and healing. Feeling themselves to be invulnerable, it is not uncommon for adolescents to push themselves psychologically and physically beyond their limits. Increasing peer pressure may encourage adolescents to aspire to be and do what it is they think others expect of them.

Adolescent development may also confound the recovery period in various ways.

It is often difficult to distinguish between developmental issues of adolescents and problems secondary to an injury, such as irritability or poor judgment.

Peer, family, or team expectations may fail to adjust to changes resulting from an injury.

Young people often lack the experience and maturity to make healthy choices and at times this may impede their rehabilitation and successful recovery after serious injury.

Mental changes including impaired judgment, decreased attention span, irritability, short-term memory loss, and memory deficits make it difficult for adolescents to adhere to a treatment regimen.

Adolescents who experience athletic injuries and must discontinue sports participation may suffer depression or other psychological symptoms (Marsh and Daigneault, 1999).

Prevention of Injuries

Most unintentional injury deaths of children can be prevented. The three key approaches to injury prevention are education, environment and product changes, and legislation or regulation. Education can serve to promote changes in individual behaviors that increase the risk of injury and/or death. Environment and product modifications can make the adolescent's physical surroundings, toys, equipment, and clothes less likely to facilitate an injury. Legislation and regulation are among the most powerful tools to reduce adolescent injury, but they also require the most energy and concentrated efforts on the part of individuals and groups.

Successful reductions in future rates of childhood and adolescent injury will require the dedication of individuals to implement evidence for what works, the determination of communities to create environments where children can grow safely, and public and private funds to support injury prevention research and disseminate effective interventions. The following lists are examples of some of the measures that may be taken to reduce injuries to adolescents.

Motor Vehicle Injuries

Adopt graduated licensing laws and policies that keep teenage drivers off the streets during late night and early morning hours.

Have parents impose restrictions and limitations of driving privileges on their teenage children.

Adopt laws restricting the number and age of passengers carried by teenage drivers (Chen et al., 2000; Grossman, 2000a).

Promote administrative license revocation that authorizes police to confiscate the licenses of drivers who either fail or refuse to take a chemical test for alcohol.

Promote primary safety belt laws that allow police to stop vehicles if the occupants are not using safety belts.

Strictly enforce zero-tolerance laws for blood alcohol in drivers younger than 21 years.

Evaluate strategies to limit access to alcohol and promote safety belt use among teenagers.

Continue to evaluate the separate components of graduated licensing systems to determine which ones are most effective.

Bicycle Injuries

Make bicycle helmets mandatory for all riders.

Impose bicycle curfews to keep riders off the streets after dark.

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Disseminate injury control recommendations on bicycle helmets.

Distribute written materials addressing all traffic laws and rules of the road in communities and schools.

Advise against riding double and freestyle stunt riding.

Drownings

Encourage swimming lessons at an early age.

Educate parents about the dangers of leaving children unattended in the bathtub or around swimming pools.

Establish a buddy system and never swim alone.

Educate people about the dangers of mixing alcohol with swimming or boating.

Mandate and enforce legal limits for BAC during water recreation activities.

Eliminate advertisements that encourage alcohol use during water recreation.

Require fencing around all public and private pools.

Restrict the sale of alcohol at water recreation facilities.

Always wear a personal flotation device while boating in open water (Grossman, 2000a).

Personal Watercraft Injuries

Require a PWC operator's license for 16- to 20-year olds.

Restrict adolescents younger than 16 years from operating a PWC unless accompanied by an adult.

Require PWC driver education for all operators.

Require helmets and life jackets for all riders.

Sports Injuries

Make the preparticipation athletic examination a requirement for all participants.

Encourage weight training and aerobic conditioning before the start of the season.

Provide medical coverage for all athletes at sporting events.

Appoint only coaches who have been properly trained and certified in youth sports.

Ensure that all athletes are properly hydrated throughout sporting events.

Appoint only officials who have been properly trained and certified in youth sports.

Ensure that all playing equipment, fields, and surfaces are safe and approved for youth sport participation.

Document the proper use of sport-specific protective equipment and distribute such items to all participants and their parents before play begins.

Check for proper safety equipment before approving players for participation in practice sessions or games.

Mandate the attendance of a certified emergency medical professional at all sporting events.

Arrange team composition based on body size and skills, not just chronologic age (Cheng et al., 2000).

TABLE 5.17Morbidity of Selected Notifiable Diseases in Children, Adolescents, and Young Adults, United States, 2005

Disease

5–14 yr

15–24 yr

25–39 yr

Total (All Ages)

NA, data not available.Adapted from Centers for Disease Control and Prevention. Summary of notifiable diseases—United States, 2004. MMWR2006a;53(53):1–79. Published June 16, 2006 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5353a1.htm.

Acquired immunodeficiency syndrome (AIDS)

110

2119

18,932

44,108

Chlamydia

NA

663,484

218,957

929,462

Gonorrhea

NA

189,629

104,451

330,132

Hepatitis A

883

887

1,20

5,683

Hepatitis B

32

664

24,435

6,212

Hepatitis C

2

119

223

720

Lyme disease

3,866

1,804

2,712

19,804

Measles

3

8

3

37

Meningococcal disease

163

275

148

1,361

Mumps

60

37

39

258

Pertussis

8,334

4,806

2,573

25,827

Syphilis (primary and secondary)

NA

1,368

3,878

7,980

Toxic shock syndrome

20

38

9

95

Tuberculosis

405

1,600

3,622

14,517

Suicide

Document the risk factors for suicide attempts and disseminate this information to parents and teachers.

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Ask questions about depression, suicidal thoughts, and other risk factors associated with suicide during routine history taking in adolescents.

Recommend that guns be removed from the home or, if present, that they be kept unloaded and locked separately from bullets or shells (Grossman, 2000a). Placing cable or trigger locks on locked guns is an added safety feature.

Homicide

Encourage use of a skills-building violence prevention and conflict resolution curriculum in the schools, from kindergarten through grade 12.

Advise parents to limit their adolescents' viewing of violence in the media and witnessing or experiencing violence in the home and neighborhood.

Encourage parents to remove guns from the home or, if guns are present, to keep them unloaded and locked separately from bullets or shells (Grossman, 2000a). Placing cable or trigger locks on locked guns is an added safety feature.

Morbidity

Notifiable Communicable Diseases

Mortality rates for adolescents are low compared with those for adults; nonetheless, there is significant morbidity among teenagers. Table 5.17 lists the morbidity rates for selected diseases among adolescents during 2004. As with adolescent deaths, many of the diseases that are contracted by adolescents are a result of health-related behaviors and lifestyle choices. For example, STDs are more prevalent among adolescents than any other population group.

Several other datasets available for understanding adolescent morbidity are reviewed in the following sections.

Hospitalizations and Outpatient Visits

Hospitalizations

According to the Healthcare Cost and Utilization Project, hospitalizations for youth between the ages of 1 and 17 years represented 4.5% of the total number of hospitalizations in the United States in 2002. Adolescent pregnancy accounts for 3% of all pediatric hospitalizations and for almost 9% of nonneonatal hospitalizations. The ten most common principal discharge diagnoses among all children aged 1 to 17, excluding those for pregnancy and pregnancy related conditions, are listed here (Merrill and Elixhauser, 2005). For ages 13 to 17, injuries (including leg fractures), medication poisonings, and head injuries, are among the most common discharge diagnoses. Affective disorders are the most common cause of hospitalization for children for nonneonatal or nonpregnancy–related conditions (Owens et al., 2003).

Tables 5.18, 5.19, and 5.20 provide additional data regarding childhood and ambulatory adolescent medical visits. Adolescents and young adults aged 15 to 24 made 70,593,000 office visits in 2004 accounting for approximately 8% of all ambulatory visits in the United States. This group made an additional 17,931,000 emergency room visits. Preventive health care visits comprised 28% of visits in this age-group and 18.5% in the 5- to 14-year age-group. The most common visits in the 13- to 21-year age-group were for normal pregnancy, routine child care, upper respiratory infections, and acne. The most common emergency room visits were for contusions, open wounds, abdominal pain, fractures, and sprains and strains.

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TABLE 5.18Number, Percentage Distribution, and Annual Rate of Office Visits for Children, Adolescents, and Young Adults Aged 5 to 24 Years, United States, 2004

TABLE 5.19Number and Percentage Distribution of Office and Emergency Room Visits for 13- to 21-Year-Olds, According to the Five Leading Primary Diagnosis Groups, United States, 2004

Primary Diagnosis Groups

Number of Visits (in Thousands)

Percentage Distribution (%)

Number of Visits per 100/persons/yr

a Figure does not meet standard of reliability or precision.Adapted from National Ambulatory Medical Care Survey: 2004 Summary. Advance data; health and vital statistics; number 374: June 23, 2006 and the National Ambulatory Medical Care Survey: 2004 Emergency Department Summary. Advance Data; Health and Vital Statistics; Number 372: June 23, at http://www.cdc.gov/nchs/products/pubs/pubd/ad/ad.htm. 2006.

All visits (office visits)

910,857

100

11.6

All visits, 13–21 yr

65,131

100

10.1

Normal pregnancy

4,033

6.2

4.3

Routine infant or child health check

3,368

5.2

1.7

Acute upper respiratory infection

2,966

4.6

1.5

Acne

2,624

4

1.1

Asthma

a

a

—

All other diagnoses

50,266

77.2

8.4

All visits (emergency room visits)

110,216

100

38.2

All visits, 13–21 yr

14,162

100

38.3

Contusion with intact skin surface

920

6.5

2.5

Open wound, excluding head

728

5.1

2.0

Abdominal pain

557

3.9

1.5

Fractures, excluding lower limb

522

3.7

1.4

Sprains and strains, excluding ankle and back

517

3.6

1.4

All other diagnoses

10,918

77.1

29.5

TABLE 5.20Number and Percentage Distribution of Office Visits by Selected Diagnostic and Therapeutic Services According to Age and Sex, United States, 1995–1996

http://www.childstats.gov. This Web site offers easy access to federal and state statistics and reports on children and their families, including population and family characteristics, economic security, health, behavior and social environment, and education. Reports of the Federal Interagency Forum on Child and Family Statistics includeAmerica's Children: Key National Indicators of Well-Being, the annual federal monitoring report on the status of the nation's children, and Nurturing Fatherhood. http://www.childstats.gov. This Web site offers easy access to federal and state statistics and reports on children and their families, including population and family characteristics, economic security, health, behavior and social environment, and education. Reports of the Federal Interagency Forum on Child and Family Statistics include America's Children: Key National Indicators of Well-Being, the annual federal monitoring report on the status of the nation's children, and Nurturing Fatherhood

http://hcupnet.ahrq.gov/. From the Agency for Healthcare Research and Quality, a tool for identifying, tracking, analyzing, and comparing statistics on hospitals at the national, regional, and state level. http://hcupnet.ahrq.gov/. From the Agency for Healthcare Research and Quality, a tool for identifying, tracking, analyzing, and comparing statistics on hospitals at the national, regional, and state level.

http://www.iihs.org. Statistics from the Insurance Institute for Highway Safety. http://www.iihs.org. Statistics from the Insurance Institute for Highway Safety.

http://www.cancer.gov/. Information from the National Cancer Institute. http://www.cancer.gov/. Information from the National Cancer Institute.

http://wwwy.cdc.gov/nccdphp/. Statistics and information on chronic diseases from National Center for Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/nccdphp/. Statistics and information on chronic diseases from National Center for Chronic Disease Prevention and Health Promotion.

http://www.cdc.gov/HealthyYouth/. Information on the Youth Risk Behavior Survey from the Centers for Disease Control and Prevention. http://www.cdc.gov/HealthyYouth/. Information on the Youth Risk Behavior Survey from the Centers for Disease Control and Prevention.

http://www.cdc.gov/nchs. Portal for national health statistics from the National Center for Health Statistics. http://www.cdc.gov/nchs. Portal for national health statistics from the National Center for Health Statistics.

http://www.cdc.gov/ncipc/ncipchm.htm. Statistics and searching tool from the National Center for Injury Prevention and Control; click either data or facts for information. http://www.cdc.gov/ncipc/ncipchm.htm. Statistics and searching tool from the National Center for Injury Prevention and Control; click either data or facts for information.

http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm. Data from the National Center for Health Statistics on ambulatory care. http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm. Data from the National Center for Health Statistics on ambulatory care.

http://www.health.gov/healthypeople/. Information on Healthy People 2010. http://www.health.gov/healthypeople/. Information on Healthy People 2010.

http://www.ahrq.gov. Overall Web site for Agency for Healthcare Research and Quality. http://www.ahrq.gov. Overall Web site for Agency for Healthcare Research and Quality.

http://www.cdc.gov. Overall Centers for Disease Control and Prevention portal for information and statistics including Mortality and Morbidity Weekly Report. http://www.cdc.gov. Overall Centers for Disease Control and Prevention portal for information and statistics including Mortality and Morbidity Weekly Report.

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National Center for Injury Prevention and Control. Facts about poisoning. Atlanta, GA: Centers for Disease Control and Prevention, Available at http://www.cdc.gov/ncipc/factsheets/poisoning.htm. 2006d.

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National Federation of State High School Associations. 2004–05 NFHS high school athletics participation survey. Indianapolis: National Federation of State High School Associations, Available at: www.nfhs.org. 2005.